Transgender Mental Health in Rural Montana

Project Leader: Adina Smith, Montana State University

Abstract

Suicide rates and suicidality among transgender persons are much higher than in the
general population. Transgender persons’ experiences of isolation, marginalization,
lack of social support, discrimination, violence and negative experiences with health
care providers put them at higher risk of developing depression, anxiety and eventually
suicidality. Although depression, anxiety and substance abuse are correlated with
suicidality, these mental disorders contribute only a partial understanding of the
factors impacting suicidality. When controlling for the presence of mental disorders,
suicide risk is still significantly higher in lesbian, gay, bisexual, transgender
(LGBT) persons, than in the general population. Montana has ranked in the top five
states for suicide for the past 30 years.

Despite it being the 6th least populated state in the United States, using frequency data from other studies,
we estimate that about 3000 transgender individuals reside in the rural state of Montana.
The already high frequency of suicide and suicidality in transgender persons may be
further exacerbated by rural-specific risk factors, such as limited availability of
services due to geographic distance, concerns about confidentiality, rural ideologies,
interpersonal isolation, and a dearth of primary healthcare providers trained to effectively
diagnose depression and anxiety and work with transgender persons. To our knowledge,
no studies have examined rural transgender suicide. Consequently, our understanding
of the complexity of factors that impact the suicidality of transgender persons in
rural areas is insufficient to effectively reduce risk and strengthen protective factors.
Our work thus far has examined the determinants of suicide within this vulnerable
population through the collection and analysis of 23 interviews statewide with transgender
persons.

We plan to expand our pilot study in order to identify the determinants of suicide
for transgender persons in rural Montana using a community-based participatory research
(CBPR) approach and from these findings will identify potential intervention strategies.
Suicide and suicidality (defined as suicide ideation and attempts) among transgender
persons are much higher than in the general population(1-3). Transgender persons’
experiences of isolation, marginalization, lack of social support, discrimination,
violence, and negative experiences with health care providers have been linked with
depression, anxiety, and suicidality(1, 4-10). Although depression, anxiety and substance
abuse are correlated with suicidality(11, 12), these mental disorders contribute only
a partial understanding of the factors impacting suicidality. When controlling for
the presence of mental disorders, suicide risk is still significantly higher in lesbian,
gay, bisexual, transgender (LGBT) persons(13), than in the general population. To
our knowledge, no studies other than ours have examined the determinants of rural
transgender suicidality. Consequently, completing our understanding of the complexity
of factors that impact suicidality of transgender persons in rural areas is critical
to effectively reduce risk and strengthen protective factors.

We use a CBPR approach, a successful methodology in working with underserved, marginalized
and hidden populations, including transgender persons, on mental health disparities.
We have found this approach to be the driving force behind the success of our project
to date. The project coordinator will use the interview protocol we developed in our
prior INBRE funding cycle to conduct in-depth interviews with 13 additional transgender
persons residing in rural areas in Montana, hoping to reach data saturation through
a more fully representative sample. The CBPR partners will translate these data into
a model illustrating the determinants of suicide and use this model to create ideas
for potential interventions to reduce suicide. Findings from this study will advance
our knowledge about the determinants of suicide in transgender persons in a rural
state and have the potential to be translated to transgender and other marginalized
populations in other areas of the U.S.

Specific Aims

Strengthen our exploration of the determinants of suicidality in rural transgender
persons. The project coordinator will use the interview protocol we developed in our
prior INBRE funding cycle to conduct in-depth interviews with 13 additional transgender
persons residing in rural areas in Montana, hoping to reach data saturation through
a more fully representative sample. We also will add to the interview protocol several
probes to increase the depth of understanding and knowledge to be gained with the
additional interviews.

Using the data collected, develop a model depicting the determinants of suicide and
identify suicide intervention strategies to be tested in a future research study.
The partners will incorporate all the collected data into a model illustrating determinants
of suicide from the perspective of transgender persons in the rural state of Montana.
The partners will explore the relationships between variables, identify our priorities
for intervention, and identify potential intervention strategies.

Prepare and submit two manuscripts and an NIH grant proposal. The partners will submit
two manuscripts to peer-reviewed journals on the findings and resubmit an NIH R21
grant proposal through the funding opportunity “The Health of Sexual and Gender Minority
(SGM) Populations.”

Innovation

We have launched the first study to examine the determinants of suicidality of transgender
persons living in the rural US.

We have successfully employed a CBPR approach to identify determinants.

This study includes perspectives from both “insiders” and “outsiders” of the transgender
community. Although some research has been conducted in urban communities, the needs
and priorities of transgender persons living in a rural state previously had not been
explored. Until we received support from INBRE for the first phase of our project
and collected data from 23 transgender participants, no other studies had conducted
research with rural transgender persons using a CBPR approach. We have accomplished
this through successfully partnering with the transgender community and their allies
in Montana to conduct all stages of the research. In this second phase of the project,
the Partners (PI, Project Coordinator, Steering Committee (SC)) will work together
on data collection, will interpret the data, finalize an intervention model, and disseminate
findings. Using a CBPR approach has increased our access to rural transgender persons
and we now have a greater comprehension of the factors that influence high rates of
suicidality. This knowledge allows for a broader perspective of rural transgender
experiences and thus a more informed intervention model. Further, our project involves
the viewpoints of “outsiders” including researchers from outside Montana in order
to create a “consensus construction of reality”(55), which allows for a broader, more
educated perspective on rural transgender experiences and thus a more informed intervention
model. The resulting intervention model will provide an original contribution by focusing
on the determinants of suicide for persons who are both transgender and reside in
a rural state.